Board Certification

EM news recently ran an article on their front page on the AAPS (American Association of Physician Specialties). The organization is suing the NY Dept. of Health because they are not listing physicians boarded by their organization on the NYDOH website.

The AAPS is an organization that will grant board certification to a specialty including Emergency Medicine. Obviously, board certification status is important since if affects the physicians ability to obtain hospital privileges, be eligible of certain types of malpractice insurance and compensation. Interestingly, the individual can become boarded without having completed a residency in EM.

The requirements according to the AAPS website and their boarding arm the ABPS (American Board of Physician Specialists) in short are as follows:

• complete a residency in anesthesiology or a primary care specialty, or

• be certified in a primary care specialty or anesthesiology by the ABPS

• complete a 12 or 24 month emergency medicine graduate training program approved by BCM and have practiced emergency medicine full-time or five years, accumulating at least 7,000 hours of practice. The graduate course cannot be substituted for a primary care or anesthesiology residency.
  

The full page of requirements can be found here.

The AAPS even recognizes three different fellowship programs. In Memphis, Tennessee, family practice residents spend one year doing an EM fellowship and can then call themselves boarded certified EM physicians.

Are alarm bells going off? This alternate boarding organization could jeopardize EM-trained physicians in a number of ways. First, patient safety. Patients are best treated in the emergency department by EM-trained physicians. Tom Scaletta, president of AAEM (American Association of Emergency Medicine) summed up this point by stating, “The AAPS does not understand that the public want board certified specialists staffing their emergency departments.” Secondly, malpractice rates may increase. Allowing AAPS board certified physicians to be credentialed could potentially increase rates, as the insurance companies can easily look at a non EM-trained physician practicing in the ED as an increased risk. Finally, compensation. Physicians staffing an ED that are not boarded in EM usually bill at a lesser rate.

Fortunately, the AAEM and ACEP (American College of Emergency Physicians) are vehemently fighting the AAPS. They have won a suit in North Carolina against AAPS and are actively fighting to preserve Board Certification status for EM-trained physicians.

If this makes sense to you, I would encourage you to contact your state legislator and express your opinion. If it does not, I would welcome your response.

Post submitted by Mike Grinney, Resident in Emergency Medicine at Lincoln Hospital, New York City.

"SoapBox" is a column designed for medically-related rantings. Whether it's a recently published article or the disgruntled clerk in your ED; this column allows the writer to express how he or she really feels.

Avoiding a headache...

As I was walking along the boulevard in Los Angeles, I witnessed a a young man trip and fall to the ground. As he fell, a car was turning close by, which gave the appearance that maybe the man was hit by the car. Quickly a crowd gathered and a discussion began about what happened. The man, clearly without injury, attempted to get up by himself but many in the crowd told him to just lie still. An ambulance arrived, took out their equipment and attempted to strap the man to a back-board. He didn't seem to have any symptoms just an abrasion across his nose.

“What are you doing?” the man asked as they put on a c-collar and strapped him to a back-board. “Do I really need this” he asked? “It’s protocol, we do this to everyone.” replied the EMS worker. “But there is nothing wrong with him, just ask him,” a family member replied.

The man didn't argue with the EMS worker but seemed upset. He was placed in the ambulance with a cervical collar in place, on a backboard and brought to the Emergency Department.

As I walked away, I began to think about what EMS said about protocol. I'm a strong believer in being cautious, but I think it is reasonable to stray from a strict protocol, occasionally. There are many protocols in place. Trauma care, chest pain, and disaster cases are some examples. But more often we are faced with situations in which we have time to think and decide and use our clinical judgment but frequently don't. We should spend more time trying to individualize protocols. If we have any sense of judgment and experience, we should use it. I hope that when this man arrives in ED, he is quickly evaluated, gets unstrapped from the back-board, removed from the cervical collar and is discharged. Likely, this was not the case. He probably walked out of the ED hours later.

Comments welcomed

Post submitted by a New York City Attending Physician in Emergency Medicine

"SoapBox" is a column designed for medically-related rantings. Whether it's a recently published article or the disgruntled clerk in your ED; this column allows the writer to express how he or she really feels.

SoapBox: You've got some nerve...

In the February 2007 edition of ACEP news an emergency physician encourages the use of regional blocks in the ED, particularly axillary blocks.

I don’t think that is something I would encourage.

I understand the basics of axillary blocks. The concern for me is the 1.45% risk of intravascular injection and subsequent seizures, or myocardial depression, prolonged cardiac resuscitation, lack of adequate remedy, and inability to use most regular meds in the ACLS protocol because it may actually worsen their toxicity.

Even if the risk of adverse effects is less than that from conscious sedation why perform a procedure whose adverse effects are potentially so deleterious?

Why does this ED physician like it so much? Here are his reasons as quoted in the article: “Shorter length of stay”, “incredibly benign”, “Can do it alone”, and “no need for IV’s.”

Say what?

Don’t tell me that there is no need for little versed or morphine to take the anxiety away.

I’m not that much of cowboy doctor to walk up to people with forearm fractures and stick a needle into their infra-clavicular space because “I can do it alone.” Oh yeah, by the way I also don’t like to do CPR for 45 minutes and then have to perform a Head CT scan because the patient isn’t waking up.

There is a place for regional blocks but it should be limited to the ones that require little doses of anesthetic, like orbital, mental, or digital blocks.

Post submitted by a New York City Attending Physician in Emergency Medicine

"SoapBox" is a column designed for medically-related rantings. Whether it's a recently published article or the disgruntled clerk in your ED; this column allows the writer to express how he or she really feels.